Treatment Authorization
Employee Name*
*
Employee DOB
*
-
Month
-
Day
Year
Date
Employee Phone*
*
Format: (000) 000-0000.
Employee Email Address
example@example.com
Employee ID #
Job Title
Employer Name*
*
Employer Phone*
*
Format: (000) 000-0000.
Employer Address*
*
Employer Email Address
example@example.com
Service(s) Authorized
Service(s) Authorized
*
Pre-employment Physical
DOT/DMV Physical
DOT Drug Screen
DOT BAT Screen
Rapid Drug Screen
Non DOT Drug Screen
Non DOT BAT Screen
TB Skin Test
TB Questionnaire
Audiogram
Pulmonary Function Test
Respirator Clearance
Mask Fit Testing
OSHA Questionnaire
Other
Date
*
-
Month
-
Day
Year
Date
Authorized Employer Contact Name
*
Authorized Employer Contact Signature
*
124 West Fesler Street
Santa Maria, CA 93458
info@umsmv.com
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